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www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/ambulatory-care/improving-communication-guide.docx
September 01, 2022 - Slide 6
Communication Model
SAY:
Even with the best of intentions, failures of communication can happen
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www.ahrq.gov/sites/default/files/wysiwyg/nhguide/5_TK2_T2-Concise_Antibiogram_Toolkit_Getting_Started.pdf
May 01, 2014 - This is highly unlikely to happen in a
nursing home.
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digital.ahrq.gov/ahrq-funded-projects/assess-risk-wrong-patient-errors-emr-allows-multiple-records-open
January 01, 2023 - “Placing orders on the wrong patient should never happen.
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psnet.ahrq.gov/innovation/system-approaches-social-determinants-health-screening-and-intervention-innovation
July 23, 2024 - It’s also important to emphasize that making significant change is a gradual process that doesn’t happen
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psnet.ahrq.gov/web-mm/lp-or-not-lp
February 01, 2018 - psychologists have long known that errors in the completion of routine tasks are particularly likely to happen
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effectivehealthcare.ahrq.gov/sites/default/files/pdf/major-depressive-disorder_consumer.pdf
September 01, 2016 - professional said you have any of these conditions:
» Seasonal affective disorder (depression symptoms that happen
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psnet.ahrq.gov/node/49476/psn-pdf
March 02, 2005 - If he did not, how could this happen?
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psnet.ahrq.gov/web-mm/wrong-side-bedside-paravertebral-block-preventing-preventable
August 10, 2019 - since they have long been included on the National Quality Forum's list of events that "should never happen
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psnet.ahrq.gov/node/72693/psn-pdf
January 29, 2021 - Similar adverse drug events related to different drug concentrations in same-size ampules also happen
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digital.ahrq.gov/sites/default/files/docs/page/2006ClancyKeyesYoung_051211comp.pdf
June 16, 2021 - about privacy and security,
but they think appropriate information exchange is
important and must happen
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www.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/strategies/labor-delivery-unit/tool-cord-prolapse.html
July 01, 2023 - Being aware of what is going on and what is likely to happen next.
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/qi-action-slides.pptx
April 01, 2022 - more authority
Communication about error: 38.9%
Driver of score: We are informed about errors that happen
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.323_slideshow.ppt
May 01, 2014 - medication reconciliation
There are many barriers and true robust medication reconciliation often does not happen
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psnet.ahrq.gov/node/851158/psn-pdf
June 28, 2023 - Ultimately, this case is an excellent example of what can happen when best
practices are not followed
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psnet.ahrq.gov/node/49423/psn-pdf
November 01, 2003 - Surgical tools left in five patients: UW surgeons take precautions to ensure it doesn’t happen
again
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www.ahrq.gov/sites/default/files/wysiwyg/sops/events/webinar/best-practices-survey-administration-webcast-sorra.pdf
January 01, 2024 - year’s safety
improvements: The survey
begins during patient
safety awareness week
Safety doesn’t
happen
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psnet.ahrq.gov/perspective/building-safety-program-using-principles-resilience-engineering
October 23, 2013 - Making it happen—from research to practice. In: Hollnagel E, Braithwaite J, Wears RL, eds.
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psnet.ahrq.gov/node/33849/psn-pdf
January 01, 2018 - We are testifying to things
that didn't actually happen, physical exam findings that we didn't do, or
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psnet.ahrq.gov/node/33791/psn-pdf
September 01, 2015 - have
this great EHR, you should be harnessing it for safety, but these transcription errors still happen
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psnet.ahrq.gov/node/33855/psn-pdf
April 01, 2018 - Every patient
is different and things happen in the hospitalization, so to get the acute situation under